Family Application :
Personal Details....
First Name:
Last Name:
Street Address:
City:
State:
AL
AK
AR
CA
CD
CT
DE
FL
GA
HI
ID
IL
IN
IA
KS
KY
LA
ME
MD
MA
MI
MN
MS
MO
MT
NE
NV
NH
NJ
NM
NY
NC
ND
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VT
VA
WA
WV
WI
WY
Area Code :
Email:
Phone Number :
Fax Number :
Mobile Phone Number :
Anyone in Your Family Smoke :
Select
Yes
No
How Many Adults in Family :
Select
1
2
3
4
5
6
7
8
9
Lifestyle :
Select
Formal
Semiformal
Casual
Relaxed
Children :
Select
Yes
No
If So How Many :
Select
1
2
3
4
5
6
7
8
9
Is Your Family Expecting :
Select
Yes
No
If So When :
Select
January
February
March
April
May
June
July
August
September
October
November
December
Pets in Home :
Select
Yes
No
If So What Kind :
Select
Dog
Cat
Both
Position Looking to fill :
Select
Babynurses
Nanny
Housekeeper
Chauffeur
Butler
Chef
Personal Assistant
Start Date :
Select
January
February
March
April
May
June
July
August
September
October
November
December
Live In :
Live Out :
Flexible :
Full Time :
Part Time :
Working Hours :
Select
24 hours
9-5
8-6
7-7 Other
Salary Offering Per Week :
Per Day :
Offering Health Insurance :
Select
Yes
No
Besides English any other Languages Spoken in Home:
Yes
No
If So What:
Responsibilities....
Baby Nurse :
Select
Yes
No
Childcare :
Select
Yes
No
Cleaning :
Select
Yes
No
Laundry :
Select
Yes
No
Ironing :
Select
Yes
No
Cooking :
Select
Yes
No
Driving :
Select
Yes
No
Errands :
Select
Yes
No
Other Skills....
Athletic :
Select
Yes
No
Biking :
Select
Yes
No
In Line Skating :
Select
Yes
No
Swimming :
Select
Yes
No
Please Tell Me About Your Family and Your Position....
Please Tell Me About Your Ideal Candidate....
